Double Burden Syndrome - A Growing Public Health Concern
Overnutrition (e.g. overweight and obesity) and undernutrition (stunting and wasting) occur simultaneously across countries, communities, households and individuals. Recognizing that both conditions share similar drivers and causes, this series explores double burden malnutrition.
Global inequalities in household-level DBM were strongly related to country income, with poorer countries suffering the greatest impact. Gender inequity also appeared strongly related to DBM; however, for men the association was less obvious.
The Dual Impact of Malnutrition and Obesity on Global Health
Malnutrition is a global challenge that demands coordinated efforts across sectors and countries to end hunger, achieve food security and improved nutrition, promote sustainable agriculture, as well as end hunger. Malnutrition impacts all areas of human life - it contributes to noncommunicable diseases like cardiovascular disease and diabetes; affects maternal and child health as well as disability, stunting, early death. Furthermore, malnutrition undermines economic development while incurring significant costs upon society as a whole.
The double burden of undernutrition and obesity has emerged as a global health problem, particularly prevalent among low- and middle-income countries (LMICs). Though most LMICs have made substantial strides toward decreasing malnutrition rates over the last 30 years, more recently they have seen significant increases in overweight and obesity rates; furthermore, over time their proportion of LMICs with double burden has increased from 45 countries to 48.
Researchers from UCL and elsewhere report in The Lancet that both issues are increasingly linked, due to rapid changes in countries' food systems. Energy-dense foods rich in fat and sugar may be driving increases in overweight and obesity among low-income communities while others suffer from undernutrition characterized by wastefulness or stunting.
As the double burden of undernutrition and overweight/obesity emerges, its implications on individual health become significant. Increased vulnerability to infectious and noncommunicable diseases as well as adverse side effects such as growth retardation, gastrointestinal disorders and inflammation all increase with undernutrition/overweight/obesity combined.
This paper investigates trends related to malnutrition - commonly referred to as the double burden - at individual, family, community and national levels. Additionally, biological mechanisms and implications are explored as well as possible policy solutions that might assist.
These papers analyze various country-level data sources, from nationally representative surveys of both general population as well as specific groups such as women, children and adolescents living with HIV to gender analyses and assessments for women living in an HIV environment. They identify risk factors associated with both undernutrition and overweight/obesity as well as examine how these relate to household socio-economic status (SES), dietary patterns and food system changes.
Understanding the Complexities
Complexity arises from the interdependence of undernutrition and overnutrition: both can contribute to long-term health issues; so treating one is unlikely to solve another - therefore effective action against Double Burden Syndrome must address both malnutrition and obesity simultaneously.
Double burden (DB) has several definitions. The most prominent are those which highlight coexistence of micronutrient deficiency and overweight/obesity at various points in one's life; others focus on coexisting of wasting and malnutrition within households - these often have lower prevalence rates but remain essential tools in identifying specific populations with particular nutritional challenges.
Note that the presence of domestic violence (DB) depends on individual and household socioeconomic characteristics; comparisons across studies with differing definitions should therefore be handled carefully, especially when applied to rural settings where drivers of DB may differ significantly from those seen among urban populations.
Recent studies conducted in rural Kenya demonstrated that domestic violence (DB) rates were highest among those with low educational attainment and lowest among those who completed high school or beyond; additionally, rates of domestic abuse were highest in those with lower incomes and lowest among the richest groups.
This study revealed that the incidence of DB was strongly related to gender inequality, with women more affected than men. Furthermore, its incidence was found to correlate with motherhood; when selection was considered in its analysis, increasing child count reduced sickness absence among workers working full time in labour markets; this finding supports theories suggesting women who balance careers with raising families are less prone to absenteeism.
Generalising, increased exposure to risk factors associated with malnutrition and poor health increases the chances of experiencing diarrheal disease (DB). Therefore, society drivers such as food production/consumption patterns, social norms/culture practices/technologies used must be considered when trying to address its causes.
Addressing the Rising Challenge
As economies expand and people live longer, the global burden of disease has been increasingly shifting towards non-communicable diseases (NCD). NCDs account for over 80 percent of all disease burden in high-income nations while communicable diseases remain significant health challenges in low-income countries.
Therefore, many LMIC are faced with the unique challenge of managing both ID and NCD simultaneously - an often unacknowleged phenomenon known as the Double Burden Syndrome. This dual burden poses unique difficulties to these nations because limited funding and resources tend to go towards combatting ID while neglecting NCD issues.
This trend is alarming given evidence demonstrating that NCDs can be reduced through targeting risk factors like obesity and undernutrition, but many interventions most effective at combatting them are often cost prohibitive for low-income nations.
Undoubtedly, addressing the Double Burden Syndrome will require an inclusive multifaceted strategy. To begin with, understanding its cause requires better assessing poverty and food insecurity levels, gender inequality levels, economic development efforts and diet habits as potential contributors to this trend.
One study discovered that both undernutrition and overweight/obesity prevalence rates were higher among women than men. This finding could be attributed to their disproportionate representation in informal labour markets with poor wages, working conditions and no social protections in place, as well as their preponderance in lower quality formal jobs where discrimination occurs and pay gaps exist.
Gender inequality in wealth distribution is another potential driver of undernutrition and obesity, and has been shown to increase odds for both conditions. Gender inequality has been associated with reduced education levels leading to poor job opportunities and productivity losses over time, which leads to insufficient income needed for adequate food intake as well as rising risks related to diet and lifestyle, ultimately increasing NCD risk. Furthermore, structural gender inequality increases vulnerability through gender-specific patterns of disease transmission and treatment - further fuelling undernutrition and obesity rates.
The Growing Burden
With globalization and urbanization causing rapid urbanization in LMICs, infectious and noncommunicable disease burden is increasing significantly, reflecting changes in lifestyles and economic development that include high fat diets, physical inactivity, smoking and alcohol abuse, limited access to quality healthcare and social support as well as lack thereof. This trend could have long-term ramifications on health outcomes unless addressed through effective policies and practices.
An integrated approach must be taken in order to address this challenge, including interventions focused on nutrition and non-communicable disease prevention and care. A recent policy brief outlined this need, calling for an integrated strategy aiming at decreasing mortality and morbidity from both causes by 2025. This can be accomplished through encouraging healthy lifestyles, decreasing dietary risk factors and developing affordable healthcare and medicines that are widely accessible.
Gender inequality has long been linked to an increased burden of disease, particularly with respect to ID and NCDs where disease burden is significantly greater in female than in male victims. Figure 2 displays differences in disease burden (measured in terms of DALYs) by gender across tertiles of a country's Gender Inequality Index.
This gap may be partially explained by society's uneven distribution of domestic duties; women tend to shoulder more domestic responsibilities than their male counterparts in most societies. Until these responsibilities are shared evenly among both husbands and wives and couples agree on making sacrifices in order to balance work life with family life, this situation will likely persist.
Single fathers who work have the added burden of trying to balance work and family life - an issue which also plagues married mothers. Furthermore, this problem affects single men not employed. A man burdened with parenting and work may find himself without time for himself, leading him down a path of diminished self-esteem or even depression and anxiety.
